Provider Demographics
NPI:1053490425
Name:OELLER, TRACY L (PA)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:L
Last Name:OELLER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6100 LAKE WORTH BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76135-3703
Mailing Address - Country:US
Mailing Address - Phone:817-237-3321
Mailing Address - Fax:817-237-7970
Practice Address - Street 1:6100 LAKE WORTH BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76135-3703
Practice Address - Country:US
Practice Address - Phone:817-237-3321
Practice Address - Fax:817-237-7970
Is Sole Proprietor?:No
Enumeration Date:2006-11-04
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01476363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP35871Medicare UPIN
TX86N204Medicare PIN
TXTXB100077Medicare PIN
TXTXB100078Medicare PIN
TXTXB123522Medicare PIN
TXTXB100079Medicare PIN